Annals for Hospitalists - April 2023
Authors: David H. Wesorick
Journal: Annals of Internal Medicine (2023)

Web ExclusivesApril 2023Annals for Hospitalists - April 2023FREEDavid H. Wesorick, MDDavid H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202304180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesSodium–Glucose Cotransporter-2 Inhibitors for Heart Failure With Preserved Ejection Fraction—What Hospitalists Need to Know—Sarah K. Adie, PharmD, and Matthew C. Konerman, MDSodium–glucose cotransporter-2 (SGLT2) inhibitors are the first class of heart failure (HF) medications that improve outcomes in patients with HF with preserved ejection fraction. In this article, expert authors explain how hospitalists can safely prescribe these medications.Highlights of Recent Articles From Annals of Internal MedicineIn The Clinic: Periprocedural AnticoagulationAnn Intern Med. 2023;176: ITC49-ITC64. Published 11 April 2023. doi:10.7326/AITC202304180This article provides a detailed review of the management of anticoagulation in the periprocedural setting.Key points for hospitalists include:Most invasive procedures require the cessation of anticoagulation, unless the bleeding risk of the procedure is minimal (for example, colonoscopy without polypectomy, pacemaker and automatic implantable cardioverter-defibrillator placement, minor dental or dermatologic procedures, cataract surgery, electroconvulsive therapy, and arthrocentesis).Vitamin K antagonists are typically held for 5 days before a procedure. Factor Xa inhibitors are typically held for 1 to 2 days, depending on bleeding risk and renal function.When holding vitamin K antagonists for a procedure, bridging anticoagulation with low-molecular-weight heparin (or intravenous heparin) is generally recommended for patients at the highest thrombotic risk, illustrated in the following groups:In patients with mechanical prosthetic heart valves, bridging is recommended in all cases except patients with bileaflet valves in the aortic position (which only requires bridging in the setting of transient ischemic attack or stroke within 6 months).In patients with atrial fibrillation, bridging is only recommended in cases of high CHA2DS2-VASc score (for example, ≥7 or 5 to 6 with history of arterial thromboembolism), or in cases with transient ischemic attack or stroke within 6 months, or rheumatic valvular disease.In patients with venous thromboembolism, bridging is recommended if the procedure is scheduled within 3 months of the venous thromboembolism event or if the patient has a known, high-risk coagulation abnormality (for example, deficiency of protein C, protein S, or antithrombin; antiphospholipid syndrome; or multiple abnormalities).Urgent procedures may require active reversal of anticoagulation. The preferred agents for reversal of vitamin K antagonists are vitamin K and prothrombin complex concentrate (fresh frozen plasma is considered a second-line option). Factor Xa inhibitors can be reversed with andexanet alfa, with prothrombin complex concentrate serving as a possible alternative.Worsening Spread of Candida auris in the United States, 2019 to 2021Ann Intern Med. 2023;176:489-495. Published 21 March 2023. doi:10.7326/M22-3469This article describes national surveillance data from 2019 to 2021 regarding C auris, an emerging, invasive Candida species. Although there were only 53 clinical cases in 2016, there were 1471 cases (in more than 20 states) in 2021. Although most C auris is resistant to azoles, echinocandin resistance is rare but increasing (from 0.4% in 2018 to 1.2% in 2020).Key points for hospitalists include:C auris is an emerging, invasive, azole-resistant pathogen that is spreading in the United States.Most cases are found in high-acuity, post-acute care facilities (for example, long-term acute care hospitals), but there have been outbreaks in acute care hospitals as well.Effectiveness of Molnupiravir and Nirmatrelvir–Ritonavir in Hospitalized Patients With COVID-19: A Target Trial Emulation StudyAnn Intern Med. 2023;176:505-514. Published 14 March 2023. doi:10.7326/M22-3057This observational target trial emulation study used electronic health databases in Hong Kong to examine outcomes for patients with COVID-19 who were admitted to non–intensive care unit (ICU) beds in 2022, during an Omicron-dominant outbreak. The authors compared patients treated with molnupiravir (n = 2700) or nirmatrelvir–ritonavir (n = 1813) with eligible patients who did not receive antiviral medications (n = 16 495 and 7119, respectively). They discovered that administration of antiviral medication was associated with lower risk for all-cause mortality but not for ICU admission or need for ventilatory support.Key points for hospitalists include:These data show an association between antiviral medications and reduced all-cause mortality for patients with COVID-19 admitted to non-ICU hospital beds; however, no association was seen between the use of these medications and other markers of disease progression (for example, ICU admission or need for ventilatory support).The reduction in mortality did not seem to differ depending on vaccination status, comorbidities, or sex. The reduction in mortality seen with molnupiravir was affected by age, with greater reductions seen in older patients.Of note, this study was done during the peak of a COVID-19 outbreak when public hospitals in Hong Kong were overwhelmed and demand for ICU care may have outstripped supply. Therefore, some patients may have died while waiting to be admitted to the ICU.The Latest Highlights From Journal ClubDo SGLT2 inhibitors improve outcomes across multiple groups of patients?SGLT2 inhibitors reduce adverse renal and CV outcomes in patients with or without diabetesAnn Intern Med. 2023;176:JC27. doi:10.7326/J23-0002This meta-analysis examined 13 randomized controlled trials enrolling patients with diabetes and high atherosclerotic cardiovascular (CV) risk, HF, or chronic kidney disease and found that, compared with placebo, SGLT2 inhibitors significantly reduced rates of kidney disease progression, acute kidney injury, a composite of CV death or hospitalization, and CV death.Does rapid medication titration improve outcomes in acute HF?In adults with acute HF, high-intensity care vs. usual care reduced a composite of death or HF readmission at 180 dAnn Intern Med. 2023;176:JC31. doi:10.7326/J23-0005This trial randomly assigned 1078 patients with acute HF to either rapid titration of guideline-directed medical therapy or usual care. The high-intensity group had a significantly lower rate of the composite outcome of death or HF readmissions at 180 days.Does selective decontamination of the digestive tract reduce mortality in ICU patients receiving mechanical ventilation?In adults receiving mechanical ventilation, selective decontamination of the digestive tract reduces hospital mortalityAnn Intern Med. 2023;176:JC35. doi:10.7326/J23-0006This meta-analysis of 32 randomized controlled trials provides moderate-certainty evidence that decontamination significantly reduces in-hospital mortality in this population but only when the decontamination included an intravenous treatment component.In patients with delirium in the ICU, does haloperidol use affect out-of-hospital survival?In adults with delirium in the ICU, haloperidol did not increase number of days alive out of the hospital at 90 dAnn Intern Med. 2023;176:JC34. doi:10.7326/J23-0007This randomized controlled trial randomly assigned 1000 ICU patients with delirium to 2.5 mg of haloperidol 3 times daily, plus additional as-needed doses, versus placebo. Survival at 90 days out of the hospital was not different between the groups.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David H. Wesorick, MDAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Disclosures:Author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Sodium–Glucose Cotransporter-2 Inhibitors for Heart Failure With Preserved Ejection Fraction—What Hospitalists Need to Know Sarah K. Adie , and Matthew C. Konerman Metrics April 2023Volume 176, Issue 4 ePublished: 18 April 2023 Issue Published: April 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...